Lithium toxicity and neurologic effects: probable neuroleptic malignant syndrome resulting from lithium toxicity.

Introduction. We present the case of a patient who developed lithium toxicity with normal therapeutic levels, as a result of pharmacokinetic interaction with Valsartan, and probable Neuroleptic Malignant Syndrome from the ensuing lithium toxicity. Case Presentation. A 59-year old black male with bipolar disorder maintained on lithium and fluphenazine therapy presented with a 2 week history of worsening confusion, tremor, and gait abnormality. He recently had his dose of Valsartan increased. At presentation, patient had signs of autonomic instability, he was confused, dehydrated, and had rigidity of upper extremities. Significant labs on admission were lithium level-1.2, elevated CK-6008, leukocytosis WBC-22, and renal impairment; Creatinine-4.1, BUN-35, HCO(3)-20.1, and blood glucose 145. CT/MRI brain showed old cerebral infarcts, and there was no evidence of an infective process. Lithium and fluphenazine were discontinued, his lithium levels gradually decreased, and he improved with supportive treatment including rehydration and correction of electrolyte imbalance. Conclusions. This case illustrates that lithium toxicity can occur within therapeutic levels, and the neurotoxic effect of lithium can include Neuroleptic Malignant Syndrome. Clinicians should be aware of the risk associated with drug interactions with lithium.

Gender differences in psychiatric symptomatology in adolescents attending a community drug and alcohol treatment program.

This study examines mental health symptoms in a cohort of adolescents with substance use disorder (SUD), and attempts to determine if mental health symptoms differed by gender. We retrospectively looked at the Beck's Youth Inventory Second Edition (BYI-II) scores of 88 clients attending a community drug and alcohol treatment service in Dublin, Ireland that were completed at intake as part of their assessment. The raw and T-scores of the male patients were compared against their female counterparts and both against their age- and gender-matched normative population. Participants were 65 boys and 23 girls with a mean age of 16.2 years. Polysubstance use was the norm. As a group, the girls had higher T scores than the boys in all the domains of the BYI-II, and these were statistically significant. Sixty (68%) of the participants had a psychological problem which was moderate or severe in at least one of the five domains. This study found that SUD girls differ from their male counterparts in having both more internalizing and externalizing psychiatric problems. We also note that comorbid psychological problems are not universal. Thus we should avoid a "one size fits all" approach to treatment such as delivering universal self-esteem enhancement interventions to all adolescents with SUD.

Irish adolescents with ADHD and comorbid substance use disorder.

OBJECTIVES: To examine the literature for drug treatment of attention deficit hyperactivity disorder (ADHD) in adolescents with co-occurring substance use disorder (SUD), the challenges posed by this, and make recommendations taking into account current trend in Ireland. METHODS: Articles published from 1992-2008 were identified using OVID-MEDLINE search using the search terms attention deficit hyperactivity disorder and substance use disorder. Studies cited include review articles, epidemiological studies, experimental researches, open and controlled trials of drugs in ADHD with comorbid SUD and clinical guidelines. No non-English language papers were included. RESULTS: Thirty-six studies were examined. A number of the papers reported on the link between ADHD and SUD, that they frequently co-occur, and there is evidence that treating ADHD can reduce the risk of future SUD. Some of the studies reviewed demonstrated the safety and effectiveness of ADHD medication on the ADHD symptoms but less so on the SUD. Concerns around stimulant abuse and diversion are valid. Although there is no current evidence of frequent diversion of ADHD medications in Ireland, this practice is prevalent in the US. Consequently psychiatrists should remain vigilant to the possibility of such diversions and take measures to address them if identified. CONCLUSIONS: The available evidence suggests that medication is not hazardous in ADHD comorbid with SUD. Pharmacological treatment of ADHD, following consideration of potential risks and benefits, is justified in the presence of SUD. Both methylphenidate and atomoxetine can be used. Stabilisation of serious SUD before pharmacotherapy is preferable, and it is advisable to provide psychological treatment to address SUD in these patients.